The Real Cost of Concussions in Youth Sports: A Risk-and-ROI Framework
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A concussion in a youth or high-school program is not a single-cost event — it is a five-category cost stack: direct medical care, lost competition and practice days under the CISG Amsterdam 2022 return-to-play protocol1, program-level standard-of-care exposure, athlete-experience and academic disruption, and reputational cost. The CDC's HEADS UP data places national 12-month sport- or recreation-related TBI incidence in children 5–17 at 6.9%2; the 2023 BJSM meta-analysis of 192 studies found a 26% reduction in concussion incidence in collision sports for mouthguard wearers3; custom pressure-laminated mouthguards specifically showed a 3.6% vs 8.3% concussion rate vs OTC in a 412-player randomized HS football trial4. The risk-mitigation math below applies these incidence numbers to a representative high-school athletic department roster and surfaces the expected events avoided, the competition days saved, and the three-year cost-of-ownership delta for a team mouthguard program.
The cost of a concussion is a five-category stack — most program budgets only see the first layer
Most athletic-department concussion-cost conversations focus on the direct medical bill, which is the smallest and most visible category. The full cost of a concussion in a youth or high-school program spans five categories, and a program budget that only addresses the first one is leaving four categories exposed.
Category 1: Direct medical care. Emergency-department evaluation, follow-up specialist visits, neuropsychological testing where indicated, imaging where indicated, and any acute treatment. This is the line item that shows up on insurance EOBs. It is also the smallest category in most published cost-of-concussion analyses, and the only category that an athletic department typically does not bear directly.
Category 2: Lost competition and practice days. The CISG Amsterdam 2022 consensus statement1 specifies a graduated 6-stage return-to-play protocol with a minimum 24-hour observation per stage — meaning a fully-protocol-adherent return takes a minimum of 6 days from symptom resolution to return-to-contact, and typically 7–14 days in practice for adolescent athletes. Symptom resolution itself averages 10–14 days in the published literature. A concussion-related absence from competition is therefore a minimum two-to-three week absence, with a meaningful fraction of athletes taking longer. For high school playoff or championship-season athletes, this is a tournament-defining absence; for collegiate athletes, it is a multi-game absence; for youth competitive teams, it is a season-defining absence.
Category 3: Program-level standard-of-care exposure. A concussion event triggers a review against the program's standard-of-care documentation. CISG-aligned1 return-to-play protocols, written concussion-management policies, equipment-evaluation records, and athletic-trainer notes are what a state regulator, a school district risk-management office, or a litigation discovery process will look for. A program that has good clinical care and incomplete documentation is exposed in a way that is invisible in the medical-bill line item.
Category 4: Athlete-experience and academic disruption. Concussions in adolescent athletes are associated with academic performance reductions during symptomatic periods, school accommodations under "return to learn" protocols, and athlete-experience disruption that compounds across multi-sport athletes. The cost is not paid by the athletic department directly, but it is paid by the athlete, the family, and the school district, and it shows up in the program's relationship with parents.
Category 5: Reputational cost. Repeated concussion events in a single program — particularly in high-profile sports — change parent-recruitment dynamics, contribute to roster decline, and shift the broader community's perception of program safety. The cost is diffuse and slow, but it compounds. Programs that visibly invest in concussion prevention earn part of this back in parent confidence; programs that do not, lose it slowly.
The five categories together are the cost-of-inaction picture, and the equipment-investment side of the math has to be evaluated against the full picture rather than just the medical bill. A custom-mouthguard team program that reduces expected concussion events on a roster by even a modest fraction can be a positive-NPV investment once all five categories enter the analysis.
The five risk-mitigation metrics that matter to an athletic director
A risk-mitigation program for concussions should be measured against five metrics, not against a single cost-savings figure. These are the metrics an athletic director presents in a budget meeting.
Metric 1: Expected concussion events avoided per roster-year. For a representative high-school football roster of 60 athletes against the CDC's youth sport-related TBI incidence baseline of 6.9%2, the program-level expected event count is approximately 4 concussions per roster-year (60 × 0.069 ≈ 4.1). Applying the 2023 BJSM meta-analytic incidence-reduction signal (IRR 0.74 for mouthguards in collision sports3) yields approximately 1 expected event avoided per roster-year. Against the Winters & DeMont 2014 custom-vs-OTC delta specifically (3.6% vs 8.3%)4, the avoided-event math is even stronger for custom over retail — a 56% relative reduction in HS-football concussion incidence between the two arms.
Metric 2: Lost competition days saved per roster-year. Each concussion event triggers a minimum 14-day absence from competition under CISG-aligned1 protocols, with typical absences running 14–21 days. One avoided concussion event therefore saves a minimum 14 competition-and-practice days per athlete. For a 60-athlete roster avoiding approximately 1 event per year, the program-level saved-days figure is 14–21 days per year — meaningful for tournament play, end-of-season schedules, and multi-sport athlete availability.
Metric 3: Standard-of-care defensibility score. A program-level investment in a custom mouthguard with documented peer-reviewed mechanism354, cited counter-evidence67, governing-body rule fit, and CISG-aligned program integration1 is the strongest standard-of-care documentation an athletic department can build. Programs that buy retail OTC mouthguards as a "compliance gesture" have a weaker defensibility position because the peer-reviewed evidence for retail mouthguard concussion-incidence reduction is mixed-to-null in older reviews67 and the FTC has flagged unsupported retail concussion-prevention claims as a category-wide compliance concern.
Metric 4: Three-year per-athlete cost-of-ownership delta. The custom-vs-OTC TCO comparison is in the table below. The headline pattern: the up-front price advantage of OTC narrows quickly once mid-season reorder frequency, audit overhead, and standard-of-care defensibility enter the math. Custom appliances run on a predictable annual replacement cycle; OTC mouthguards degrade within a single season — Winters & DeMont measured average OTC thickness dropping from 1.65 mm at season start to 1.34 mm at time of injury4.
Metric 5: Parent-communication and recruitment effect. A visible program-level investment in custom concussion-protection equipment, with documentation provided to parents at enrollment, is a parent-recruitment and parent-retention asset. The cost of this metric is diffuse and slow but compounds across multi-year cohorts; a program with visibly weaker concussion-protection investment loses parents over time relative to peer programs. This metric does not have a clean dollar figure, but every athletic director and every parent-communication coordinator knows it is real.
How the expected-events math works for a representative roster
The risk-mitigation case rests on a simple piece of arithmetic that any athletic director can replicate against their own roster. The inputs are: (a) roster size, (b) baseline sport-specific or age-specific concussion incidence, and (c) the relative-risk reduction factor for the equipment category being evaluated. The outputs are expected events per roster-year with and without the equipment, and the difference.
For a representative high-school football program with a 60-athlete roster, against the CDC's national 12-month sport-related TBI incidence baseline of 6.9% for children 5–172, the baseline expected event count is approximately 4 concussions per roster-year. The 2023 BJSM meta-analysis3 reports an incidence rate ratio of 0.74 for mouthguards in collision sports — a 26% reduction. Applying that reduction to the baseline yields approximately 3 expected events per roster-year with broad mouthguard adoption, vs 4 without — approximately 1 event avoided. For the custom-vs-OTC layer specifically, Winters & DeMont 2014 reported 3.6% vs 8.3% in 412 randomized HS football players4; against the same 60-athlete roster, that delta is approximately 2.8 events per year vs the baseline OTC arm at 5 events — closer to 2 events avoided per roster-year by upgrading from OTC to custom.
The same math runs for other sports and other roster sizes. A 25-athlete ice hockey roster at a similar baseline incidence yields approximately 1.7 baseline events, with the meta-analytic reduction yielding approximately 0.4 events avoided. A 50-athlete lacrosse roster yields approximately 3.5 baseline events with approximately 0.9 events avoided. For multi-sport athletic departments — football, hockey, lacrosse, wrestling, soccer — the events-avoided figure compounds across the sport portfolio.
The honest caveat: meta-analytic effect sizes pool across many study contexts, and an individual roster's actual experience will vary. The two reasons to do the math anyway are that (a) it gives the athletic director a defensible expected-value figure for the budget meeting, and (b) the math is consistent with the controlled-trial evidence on the custom-vs-OTC sub-question4. We cite the counter-evidence67 alongside the supportive sources — that is what makes the expected-events figures credible rather than promotional.
Three-year per-athlete cost-of-ownership table (illustrative)
The cost-of-ownership math is the other half of the risk-mitigation case. The numbers below are illustrative and depend on roster size, vendor quotes, and replacement frequency — always request a vendor quote against your specific roster. The point of the table is to show where the costs sit across three years, not to provide a final budget number.
| Cost Category | Year 1 | Year 2 | Year 3 |
|---|---|---|---|
| Custom mandibular team program: initial appliance | Single unit per athlete, team-discount pricing | Annual replacement cycle, team-discount pricing | Annual replacement, team-discount; re-fit covered for actively-growing athletes |
| Custom mandibular team program: fitting workflow | On-site visit or mail-in impression kit | Re-fit only as needed | Re-fit only as needed |
| Custom mandibular team program: warranty / in-season repairs | Material/fit defects covered | Material/fit defects covered | Material/fit defects covered |
| OTC retail mouthguard program: initial appliance | $5–$30 per unit retail | Per-season reorder | Per-season reorder |
| OTC retail mouthguard program: mid-season reorders | Effectively required — average OTC thickness drops 1.65 → 1.34 mm at time of injury4 | Same pattern | Same pattern |
| OTC retail mouthguard program: warranty | Generally none for material degradation | Same | Same |
| Athletic-trainer audit overhead (custom) | Low — annual cycle is predictable | Low | Low |
| Athletic-trainer audit overhead (OTC) | High — material degradation auditing is the program's responsibility | High | High |
| Compliance audit cost (custom) | Low — high in-mouth retention | Low | Low |
| Compliance audit cost (OTC) | High — material degradation drives compliance erosion | High | High |
| Standard-of-care defensibility (custom)1 | High — peer-reviewed mechanism, CISG-aligned program documentation | High | High |
| Standard-of-care defensibility (OTC) | Low — peer-reviewed concussion evidence for retail mouthguards is mixed-to-null per Daneshvar6 | Low | Low |
The pattern the table surfaces: the retail OTC up-front price advantage narrows quickly once mid-season reorder frequency, audit overhead, and standard-of-care defensibility enter the analysis. The protective-effect side (3.6% vs 8.3% concussion incidence per Winters4) is the other half. An athletic department evaluating concussion-protection investment should consider both halves and weigh them against the size of the roster and the sport profile. The deeper program-procurement walkthrough is on the team mouthguard program buyer's guide.
Lost competition days are the hidden cost category — and the one athletic directors underestimate most
The medical-bill line item is the visible cost of a concussion. The lost-competition-and-practice days are the hidden cost, and they are the cost category that athletic directors and head coaches systematically underestimate when budgeting for concussion-protection equipment.
The CISG Amsterdam 2022 consensus statement1 specifies a graduated 6-stage return-to-play protocol with a minimum 24-hour observation per stage. The stages are: (1) symptom-limited activity, (2) light aerobic exercise, (3) sport-specific exercise, (4) non-contact training drills, (5) full-contact practice, (6) return to sport. A fully-protocol-adherent return takes a minimum of 6 days from symptom resolution to return-to-contact, with most athletes taking 10–14 days in practice. Symptom resolution itself averages 10–14 days for adolescent athletes in the published literature. The end-to-end concussion-related absence from competition is therefore typically 14–21 days, with longer absences for athletes whose symptoms take longer to resolve.
For a high school football program, 14–21 days is approximately 2–3 games at peak season. For a hockey program with a denser schedule, it is 4–6 games. For a multi-sport athlete in the back half of an academic year, it is often a sport-ending absence — the athlete misses the remainder of one sport's competition season and may also be delayed from beginning the next sport. For tournament or playoff seasons, the absence can be tournament-defining. For collegiate athletes, the absence is a multi-game stretch with knock-on effects on lineup planning. For youth competitive club athletes, it is often a season-defining absence.
The risk-mitigation case for a custom mouthguard team program is built around reducing the expected number of concussion events, and therefore the expected number of these multi-week absences. For a 60-athlete football roster with approximately 1 expected event avoided per year (against the 2023 BJSM meta-analytic reduction3), the program saves approximately 14–21 athlete-days of competition per year — meaningful at tournament time, meaningful for end-of-season schedule density, and meaningful for the program's overall performance trajectory. The same math runs across the sport portfolio; multi-sport departments compound the saved-days figure across rosters.
Standard-of-care defensibility is the hardest cost category to see — and the most expensive when it's missing
The five-category cost stack includes a category that is almost invisible in normal program operations and almost always expensive when it is missing: program-level standard-of-care defensibility. This is the category that activates when a concussion event triggers a review by a state regulator, a school district risk-management office, or a litigation discovery process.
The CISG Amsterdam 2022 consensus statement1 is the international standard-of-care framework for concussion management. It is adopted by NCAA, NFHS, USA Hockey, US Lacrosse, NFL, and equivalent international bodies, and the state-level athletic regulatory codes that overlay it generally reference CISG-aligned protocols. A program that has a CISG-aligned return-to-play protocol, written concussion-management policies, equipment-evaluation records, and athletic-trainer notes that document peer-reviewed mechanism rationale for the equipment selected has built the documentation a state regulator or risk-management review would look for.
A program that has good clinical care and incomplete documentation is in a different position. The medical bill is paid, the athlete recovers, but the program is exposed in ways that are invisible until a review happens. The cost of incomplete documentation is bimodal: zero most years, large in the year the review occurs. For an athletic department, the budget logic on this category is the same as the budget logic on insurance — pay a small predictable amount each year to avoid a large unpredictable cost when the review happens.
A custom mouthguard team program with peer-reviewed mechanism354, cited counter-evidence67, governing-body rule documentation, and CISG-aligned program integration1 is one of the strongest standard-of-care documentation assets an athletic department can build. The vendor-evaluation framework on the team mouthguard program buyer's guide is structured around producing exactly this documentation. Programs that bought retail OTC mouthguards as a "compliance gesture" have a weaker defensibility position because the peer-reviewed evidence for retail mouthguard concussion-incidence reduction is mixed-to-null in older reviews67 and the FTC has flagged unsupported retail concussion-prevention claims as a category-wide compliance concern.
How an athletic director pitches a concussion-protection budget request
The cost-of-inaction case is meant to be presentable in a budget meeting. The structure that works has four sections and runs about 15 minutes.
Section 1 (3 minutes): The problem at this program's scale. Open with the CDC HEADS UP baseline figures (6.9% sport-related TBI incidence in children 5–172; 15.1% self-reported sport-related concussion prevalence in HS students via DePadilla 2018 MMWR data2) and apply them to this specific program's roster size and sport mix. Surface the expected events per roster-year. Surface the lost competition-days figure for the highest-impact sport on the roster.
Section 2 (4 minutes): The five-category cost stack. Walk through the categories — direct medical, lost competition days, standard-of-care exposure, athlete-experience disruption, reputational cost. The point is not to put a dollar on every category; it is to surface the categories that the budget conversation usually omits and to make the program's exposure legible to the decision-maker.
Section 3 (5 minutes): The intervention case. Present the 2023 BJSM meta-analysis3 (26% concussion-incidence reduction, 192 studies) and the Winters 2014 RCT4 (3.6% vs 8.3%, p=0.0423) as the peer-reviewed efficacy base. Cite the counter-evidence (Daneshvar 20116, Benson 20097) honestly — the credibility of the supportive case depends on the counter-evidence being on the slide too. Present the three-year TCO table and the expected-events-avoided figure for this specific program.
Section 4 (3 minutes): The standard-of-care framing. Close with the CISG Amsterdam 20221 standard-of-care framework, the governing-body rule documentation89, and the parent-communication packet structure. The decision-maker should leave the meeting with the answer to "what does our program have in place that addresses this risk?" — which is a different question than "did we buy mouthguards?"
The full team-procurement walkthrough that supports this budget pitch is on the team mouthguard program buyer's guide. The category-level concussion-protection framework is on the concussion protection buyer's guide. The mechanism-level explanation is on how mouthguards reduce concussion risk.
Frequently asked questions
What is the baseline rate of sport-related concussions in youth athletes?
The CDC's HEADS UP data places national 12-month sport- or recreation-related TBI incidence in children 5–17 at 6.9%2, with a more restrictive "probable" SRR-TBI rate of 3.3%. In high school-aged athletes specifically, self-reported sport-related concussion prevalence runs at 15.1% (DePadilla 2018 MMWR data cited via2). Concussion incidence varies meaningfully by sport — football, hockey, lacrosse, and women's soccer carry higher rates than baseball, basketball, or volleyball — and a program-level analysis should run the math against the specific sport mix on the roster.
How long is a CISG-aligned return-to-play protocol?
The CISG Amsterdam 2022 consensus statement1 specifies a graduated 6-stage protocol with a minimum 24-hour observation per stage: symptom-limited activity, light aerobic exercise, sport-specific exercise, non-contact training drills, full-contact practice, return to sport. The minimum end-to-end time from symptom resolution to return to sport is 6 days. Most adolescent athletes take 10–14 days in practice, and symptom resolution itself averages 10–14 days. The end-to-end concussion-related absence from competition is therefore typically 14–21 days.
How do I estimate expected concussion events for my roster?
Multiply roster size by baseline sport-specific or age-specific concussion incidence. For a representative 60-athlete HS football roster against the CDC's national 6.9% youth TBI incidence2, the baseline expected event count is approximately 4 concussions per roster-year. Apply the relative-risk reduction factor for the equipment being evaluated — the 2023 BJSM meta-analytic IRR of 0.74 for mouthguards in collision sports3 is the strongest single source — to estimate expected events with the equipment in place. The custom-vs-OTC sub-question is governed by the Winters & DeMont 2014 trial (3.6% vs 8.3%)4. The honest caveat is that meta-analytic effect sizes pool across many study contexts, and individual roster experience varies.
Does insurance cover the medical cost of a concussion?
For most insured families, direct medical care for a concussion is covered subject to copays, coinsurance, and deductibles. The medical-bill line item is the smallest of the five cost categories for a youth athletic department and is the only category an athletic department typically does not bear directly. The remaining four categories — lost competition days, standard-of-care exposure, athlete-experience disruption, reputational cost — are not insurance-covered and accrue at the program level.
What's the standard-of-care exposure if our program doesn't have a concussion-management policy?
State-level athletic regulatory codes vary, but all 50 US states have passed youth-athletics concussion-management legislation since 2010, and most state codes reference CISG-aligned1 protocols either directly or by reference to the state department of health's standard-of-care framework. A program without a written concussion-management policy, documented equipment-evaluation records, athletic-trainer notes, and CISG-aligned return-to-play protocols is exposed during a state regulatory review, a school district risk-management audit, or a litigation discovery process. The cost of incomplete documentation is bimodal — zero most years, large in the year the review occurs.
How does a custom mouthguard team program reduce program-level cost?
The risk-mitigation math runs on three levers: (1) expected concussion events avoided (driven by the 26% meta-analytic incidence reduction3 and the larger custom-vs-OTC delta from the Winters trial4); (2) lost competition days saved (14–21 days per avoided event); (3) standard-of-care defensibility improvement (peer-reviewed mechanism, cited counter-evidence, governing-body rule fit, CISG-aligned program integration). Add the three-year per-athlete cost-of-ownership comparison and the program-level math typically favors a custom mandibular appliance over a retail OTC mouthguard once all categories are included.
Where does the equipment-vs-protocol split fall in CISG-aligned programs?
Equipment is one layer of a CISG Amsterdam 2022-aligned1 concussion-prevention program. The protocol layer — preseason baseline neurocognitive testing where applicable, in-game suspected-concussion identification and removal, graduated 6-stage return-to-play, return-to-learn coordination with the school — is the post-injury management half. A program with good equipment and an out-of-date return-to-play protocol is not a concussion-prevention program; a program with a CISG-aligned protocol but unevaluated equipment is incomplete. Both layers belong in the program manual and the parent-communication packet, and the budget pitch should address both.
What does NeuroGuard+ provide for athletic-department buyers?
NeuroGuard+ Team Ordering is a custom mandibular-stabilization program built around the criteria in the team mouthguard program buyer's guide. It includes on-site or mail-in impressions, annual replacement cycle, team-discount pricing, a coach-and-AT compliance playbook, governing-body rule documentation, and CISG-aligned program integration. The mechanism — custom lower-jaw appliance, mandibular physiologic rest position — is the family with the strongest direct peer-reviewed signal in the mouthguard literature54. We cite the counter-evidence (Daneshvar 20116, Benson 20097) on every page that touches a concussion claim, and we use FTC-defensible language throughout. The risk-mitigation math above is what an athletic director needs to make the budget case; the procurement framework is the team mouthguard program buyer's guide; the player-side compliance evidence is on mouthguard player compliance.
References
- 1. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport — Amsterdam, October 2022. British Journal of Sports Medicine. 2023;57(11):695-711. doi:10.1136/bjsports-2023-106898
- 2. Centers for Disease Control and Prevention. HEADS UP — Data on Sports and Recreation Activities. Updated 2024. cdc.gov/heads-up
- 3. Eliason PH, Galarneau JM, Kolstad AT, et al. Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis. British Journal of Sports Medicine. 2023;57(12):749-761. doi:10.1136/bjsports-2022-106656
- 4. Winters JE Sr, DeMont R. Role of mouthguards in reducing mild traumatic brain injury/concussion incidence in high school football athletes. General Dentistry. 2014;62(3):34-38.
- 5. Hutchison DD, Madura C, Hutchison MC. Impact of an improved mandibular rest position via custom mouth guard on the incidence of concussions in athletes. Michigan State University College of Human Medicine; Helen DeVos Children's Hospital; 2018. Note: corresponding author Dr. Michael Hutchison invented the studied appliance. manuscript PDF
- 6. Daneshvar DH, Baugh CM, Nowinski CJ, McKee AC, Stern RA, Cantu RC. Helmets and Mouth Guards: The Role of Personal Equipment in Preventing Sport-Related Concussions. Clinics in Sports Medicine. 2011;30(1):145-163. doi:10.1016/j.csm.2010.09.006
- 7. Benson BW, Hamilton GM, Meeuwisse WH, McCrory P, Dvorak J. Is protective equipment useful in preventing concussion? A systematic review of the literature. British Journal of Sports Medicine. 2009;43(Suppl 1):i56-i67. doi:10.1136/bjsm.2009.058271
- 8. National Federation of State High School Associations. Sport Rule Books (Football, Ice Hockey, Lacrosse, Field Hockey, Wrestling). Annual editions. nfhs.org
- 9. NCAA Playing Rules Oversight Panel. Sport Rule Books (Football, Ice Hockey, Lacrosse, Field Hockey). Annual editions. ncaapublications.com
